Treating Adult Substance Abuse Using Family Behavior Therapy: A Step-by-Step Approach

257 Pages·2011·2.76 MB·English

by  Brad Donohue

TREATING ADULT
SUBSTANCE ABUSE
USING FAMILY
BEHAVIOR THERAPY
A STEP-BY-STEP APPROACH
BRAD DONOHUE
DANIEL N. ALLEN
John Wiley & Sons, Inc.
This book is printed on acid-free paper. (cid:2)
Copyright© 2011 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act,
without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the
Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, [phone], fax [phone], or on the web at www
.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc.,
111 River Street, Hoboken, NJ 07030, [phone], fax [phone].
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no
representations or warranties with respect to the accuracy or completeness of the contents of this book and specifi cally disclaim any implied
warranties of merchantability or fi tness for a particular purpose. No warranty may be created or extended by sales representatives or written
sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional
where appropriate. Neither the publisher nor author shall be liable for any loss of profi t or any other commercial damages, including but not
limited to special, incidental, consequential, or other damages.
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the
understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other
expert assistance is required, the services of a competent professional person should be sought.
Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley & Sons, Inc. is
aware of a claim, the product names appear in initial capital or all capital letters. Readers, however, should contact the appropriate companies
for more complete information regarding trademarks and registration.
For general information on our other products and services please contact our Customer Care Department within the United States at
[phone], outside the United States at [phone] or fax [phone].
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
For more information about Wiley products, visit our website at www.wiley.com.
Library of Congress Cataloging-in-Publication Data:
Donohue, Brad.
Treating adult substance abuse using family behavior therapy: a step-by-step approach / Brad Donohue, Daniel N. Allen.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-62193-6 (pbk. : alk. paper); 978-1-118-01320-5 (ePDF); 978-1-118-01321-2 (eMobi); 978-1-118-01322-9 (ePub)
1. Substance abuse—Treatment. 2. Family psychotherapy. 3. Behavior therapy. I. Allen, Daniel N. II. Title.
[DNLM: 1. Substance-Related Disorders—therapy. 2. Adult. 3. Behavior Therapy—methods. 4. Family Therapy—methods. WM 270]
RC564.D66 2011
616.89’156—dc22
2010039797
Printed in the United States of America
10 9 8 7 6 5 4 3 2 1
Contents
Foreword by Nate Azrin v
Preface vii
Acknowledgments xi
Chapter 1 Introduction to Family Behavior Therapy 1
Chapter 2 Infrastructure 19
Chapter 3 T herapeutic Style, Techniques, and Implementation
Strategies 47
Chapter 4 E stablishing Effective Agendas for Treatment
Sessions 63
Chapter 5 E stablishing Goals and Rewards for Maintaining
a Drug-Free Lifestyle 71
Chapter 6 Developing a Successful Treatment Plan 97
Chapter 7 Enhancing Relationships 107
Chapter 8 E nhancing Communication Skills 121
Chapter 9 R estructuring the Environment to Facilitate
a Drug-Free Lifestyle 137
Chapter 10 Managing Negative Behaviors, Thoughts,
and Feelings 169
Chapter 11 Gaining Employment 197
Chapter 12 Managing Finances 213
Chapter 13 C oncluding Treatment and Planning for Success 227
iii
iv Contents
References 233
Author Index 237
Subject Index 238
About the Authors 244
Study Package Continuing Education Credit Information 245
About the CD-ROM 249
Foreword
The authors have written a treatment guide for adult drug users that is a
“must-read” for all who deal with this problem. The book is a veritable model
of an effective and practical guidebook. Simultaneously, it provides an inte-
grated approach encompassing virtually every aspect of treatment while also
providing details of the specifi c aspects of treatment that are readable and
complete as separate aspects.
No important components of treatment are left out, as topics covered
separately include the initial recruitment of clients, session attendance, fam-
ily member participation, treatment planning, treatment integrity measures,
counselor style, treatment content, and so on. Each section is valuable in its
own right whether utilized in the present program or as a component of any
other program. Thus, this book is of value and utility to any other program
approach.
Notably, almost all guidelines are accompanied by tables or outline
charts that provide the specifi c steps and often sample verbatim statements.
No vague generalizations or platitudes here. At the same time, the client
participates actively in the choice and order of treatment procedures used.
The book, as the title implies, incorporates behavior therapy, as well as the
central features of family therapy, group therapy, behavior analysis, motiva-
tional therapy, and cognitive therapy. The authors have not allowed concep-
tual purity to obstruct the principal objective of therapeutic success. Some
of the recommendations are so practical and conceptually valid that I found
myself repeatedly thinking: “What a wonderful program for treating adult
addiction.”
Nate Azrin
v
Preface
We decided to write this book while on an airplane after a wonderful experi-
ence training a treatment agency in Meadville, Pennsylvania to use Family
Behavior Therapy (FBT). Although Dan and I had worked as colleagues in a
number of research studies, this was our fi rst experience conducting training
together. The agency was located in a small, working-class town similar to
the ones in which Dan and I were raised, and we appreciated how warmly
they treated us and how passionate they were to learn FBT. We were both so
excited after the training that as soon as we sat down in the plane, Dan started
brainstorming methods of teaching FBT more effectively, which included the
writing of this book. His generation of ideas brought back great memories for
me of Nathan Azrin, who used to do a lot of problem solving in our research
meetings developing FBT. Nate would start our brainstorms by asking what
could be done to ameliorate some aspect of the therapy that appeared to be
problematic. We’d generate dozens of solutions, with each solution building
from the previous one. When we’d all agree on a group of viable solutions,
we’d change the respective intervention protocol, and all therapists would
attempt the revised therapy with our clients. We’d then regroup in a subse-
quent meeting and repeat the process until the problem was solved empiri-
cally. Nate’s philosophy was that no single idea could be suffi cient, although
every single idea was important. He insisted that if just one client experienced
a problem with a protocol, it needed to be revised to accommodate others who
would inevitably have similar concerns. Having extremely high standards
in the quality of service delivery, he was a model in positive reinforcement,
which is embedded throughout FBT. Now, some 20 years after our initial t rials,
each of the intervention components reviewed in this book has undergone
vii
viii Preface
dozens of revisions based on the input of a diverse group of research assistants,
community treatment providers, and consumers. These efforts have resulted
in a robust, comprehensive, and theoretically sound behavioral intervention
capable of treating a wide array of problem behaviors in addition to substance
abuse, such as family dysfunction, employment, and mood disorders.
Although there are a number of innovative features making up FBT,
community mental health providers consistently indicate that its compre-
hensive, fl exible, step-by-step method of implementation most differenti-
ates it from other intervention approaches. As will be reviewed in Chapter
1, each of the FBT intervention components is organized into a series of
therapeutic instructions. Each step is part of an intervention sequence that
builds upon the previous step. The format is refreshingly straightforward,
as therapists are free to exercise their own positive style when implementing
each step. Moreover, therapists often integrate information between steps to
assist in clarifi cation, engagement, and so on. Other innovative features of
FBT include its tight integration of (1) standardized and time-effi cient goal-
setting procedures that are tied to specifi c drug use triggers and competing
rewards, treatment planning, and treatment termination; (2) pragmatic uti-
lization of therapists in assessing their own estimates of treatment integrity;
(3) ongoing standardized assessment of the extent to which consumers par-
ticipate and are satisfi ed in therapy; (4) standardized client record-keeping
procedures and accompanying quality assurance system; and (5) strong evi-
dence base in treating drug abuse and other associated problem behaviors.
Each of these factors is very important to treatment delivery, although very
few programs do so reliably.
This book, therefore, provides an overview of FBT as applied to the treat-
ment of adult substance abuse, including its strong research base and step-
by-step application. Although FBT has been indicated as an established
evidence-based practice in both adults and adolescents, we decided to focus
on adults in this book, and follow with Treating Adolescent Substance Abuse
Using Family Behavior Therapy to appropriately address the many develop-
mental issues that defi ne these very distinct populations. FBT involves the
administration of psychometrically validated assessment measures and
well-established behavioral intervention components (i.e., goal setting,
contingency management, environmental/stimulus control, self-control,
communication skills training, relationship enhancement, and job-getting
and fi nancial management skills training). Each intervention component is
Preface ix
systematically described, including an overview of the intervention
approach, rationale for its use, requisite materials, and detailed description
of the intervention procedures (including implementation dialogue between
therapist and client). Protocol checklists that summarize each of the major
intervention modules are provided to assist therapists as prompts dur-
ing therapy sessions (i.e., “cheat sheets”). Within each chapter, case exam-
ples and completed worksheets assist in bringing the interventions to life.
This systematic organization permits readers to quickly identify and skim
through parts of each chapter that may be particularly relevant. For instance,
if a therapist experiences a problem implementing a particular intervention,
this therapist may quickly review the detailed descriptions of this interven-
tion, including the appropriate dialogue, to assist in determining how to pre-
vent or manage this problem in the future.
This book is primarily intended for mental health treatment providers
who are interested in learning FBT. However, professors who teach sub-
stance abuse treatment (or other clinical intervention courses) are particu-
larly encouraged to use this book in their courses. Indeed, there is ample
information available to suggest that students who will go on to become
mental health professionals need training in evidence-based therapies, such
as FBT, and that these interventions should be integrated within their class
curriculums. Along these lines, this book will likely be quite useful, as each
chapter represents a particular intervention that may be taught in a typi-
cal academic week. Qualifi ed community mental health treatment provid-
ers may gradually learn each of the interventions at their own pace, as each
treatment component may be implemented independent of the other. Indeed,
some interventions may be employed to address multiple problem behav-
iors, or they can be adjusted to focus on particular concerns. To assist in dis-
semination, this book includes all necessary materials that will be required to
implement FBT in the back of each chapter, including the prompting check-
lists, handouts, and worksheets. Of course, the method of implementation
for each of these materials is extensively reviewed in the narrative section
of each chapter. We hope you fi nd the book rewarding and the interventions
exciting to implement.
Brad Donohue
Daniel N. Allen
Acknowledgments
We would like to acknowledge our families, particularly our wives, Denise
and Ann, for their encouragement in writing this book and continued love
and support. We are particularly thankful to Nathan Azrin for his role in lead-
ing the initial development of FBT and his continued mentorship. Of course,
we would like to thank our colleagues and students who have signifi cantly
enhanced FBT throughout the years. Finally, we are grateful to the National
Institute on Drug Abuse and National Institute of Mental Health for their
support of FBT in randomized controlled trials.
xi
1
CHAPTER Treating Adult Substance Abuse Using Family
Behavior Therapy: A Step-By-Step Approach
by Brad Donohue and Daniel N. Allen
Copyright © 2011 John Wiley & Sons Inc.

Introduction to Family
Behavior Therapy
Overview
This chapter provides an overview of the application of Family Behavior
Therapy (FBT) in adults. First, the historical, theoretical, and empirical under-
pinnings of FBT are reviewed to assist in understanding its conceptualization
and development during the past 20 years. The chapter then delineates indi-
viduals who are most likely to benefi t from FBT, and recommendations are
offered in determining an assessment method that may be utilized to develop
effective treatment plans. Although content of each of the FBT intervention
components is extensively reviewed in Chapters 5 through 12, a summary of
each component is provided in this chapter to show how they are integrated
in treatment administration. The method of using checklists to guide mental
health service providers in treatment implementation is reviewed, and proce-
dures involved in the assessment of treatment integrity are underscored.
Chapter at a Glance
➣
Historical, theoretical, and empirical background of FBT
➣
Which clinical populations are appropriate for FBT, and in which therapeu-
tic contexts
➣
General structure of FBT
➣
Maintenance and assessment of FBT intervention integrity
Historical and Theoretical Background
Family Behavior Therapy (FBT) was initially developed by Nathan Azrin, Brad
Donohue, and their colleagues with the support of the National Institute on
Drug Abuse and National Institute of Mental Health. In 1989, Nathan Azrin
1